SBI General Insurance Company Limited

IRDAI Reg. No. 144 dated 15/12/2009 | CIN: U66000MH2009PLC190546 | UIN: SBG-OT-P13-106-V01-12-13

Call (Toll Free)

CATTLE INSURANCE POLICY 1800 22 1111 | 1800 102 1111
www.sbigeneral.in

Proposal Form
Guidelines for completion of the form: 1. Please answer all the questions fully and correctly. Where any question does not apply, please mention clearly that the same is not applicable.
2. Kindly contact SBIGIC’s Offices or Agents for any doubts or clarifications on the proposal form.
Note: The liability of SBIGIC does not commence until this proposal has been accepted by SBIGIC and premium paid and upon full realization of the premium payment by the Company, which acceptance shall be
specifically intimated to the Proposer by the Company along with the date from which the insurance Cover shall become effective and the insurance cover shall only be effective from the date as intimated by the
Company. If we do not accept this Proposal, we will inform you and refund any payment received from you without interest.
INTERMEDIARY DETAILS (* Mandatory Fields if Sales Channel Type selected is Banca)

Segment Type Corporate Retail SME Business Sector Urban Rural Social

Business Type New Roll-over Renewal Sales Channel Type Banca Agency Direct

Sales Channel Code Specified Person’s Code*

Specified Person’s Name*

GSTIN/ISDN IF APPLICABLE DOB of Intermediary

PROPOSER DETAILS

1. Duration of cover required 1 year 2 Years 3 Years

2. Policy Period From to

3. Name of the Proposer

4. Address of the Proposer

Pin Code

5. Address if animals are stabled

at other than above address

Pin Code

6. PAN No. 7. DOB of Proposer

8. Give the following particulars in full, of each of the animals proposed for insurance (add extra sheets if required)
Type of Animal Gender Age Description of the Animal Market Value / Ear Tag No. Vaccination details

Cow, Buffalo, M/F Color Breed of animal Purpose of the Sum Insured (if any)
Stud Bull, (Indigenous/ animal
Bullock Crossbred/Exotic)

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9. Please state whether a certificate of good health issued by a qualified veterinary doctor for each animal proposed for insurance is attached Yes No
10. Please mention the existing diseases for the animal to be covered __________________________________________________________________
11. Whether own Veterinary Services available? Yes No
12. Provide following information, in case of farm \ Is a qualified Veterinary Doctor employed to look after the animals? Yes No

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Corporate & Registered Office: ‘Natraj’, 301, Junction of Western Express Highway & Andheri - Kurla Road, Andheri (East), Mumbai - 400 069.
13. Have you lost any animal/s during the last three years? If so state particulars. Year Cause of Loss Number of animals lost

14. Previous Cattle Insurance Policy and Claims experience (for the last three years)
Year Type of animal Cow, Buffalo, Name of Insurer Claim Amount Whether claim settled in full or
Stud Bull, Bullock in part or outstanding or repudiated.

15. Has any Company

- Declined to issue a policy to you? Yes No
- Declined to continue your Insurance? Yes No
- Imposed any restriction or special conditions? (If yes, please furnish the details)
Yes No

16. Is any bank or other financing institution interested In the animal,

If so, state - Name of Bank Location of Branch

17. Is/are the animal/s proposed for insurance covered by IRDP

or any other similar scheme? If so, state Name of Scheme Yes No

18. Any other information material to the risk or the terms

upon which cover might be offered.

19. Corporate Yes No 19. GSTIN/ISDN IF APPLICABLE

ELECTRONIC INSURANCE ACCOUNT DETAILS SECTION

I want CATTLE INSURANCE POLICY and related information in Physical Format e Format (electronic); as & when applicable
Choose your Insurance Repository (For those selecting e-Format)
NSDL Data Management Ltd. CDSL Insurance Repository Ltd Karvy Insurance Repository Ltd. CAMS Repository Services Ltd
I have e Insurance Account & the No. is

My CKYC No. (Central Know Your Customer registry number) is (If available)

PAYMENT DETAILS (Claim/Refund amount will be deposited in this bank account only unless changed subsequently)
Please draw your Cheque (A/c payee only) in the name of “SBI General Insurance Company Limited” (*Mandatory fields)
Cheque No/DD No. Amount Date D D M M Y Y Y Y

Bank Name Branch

Bank Account No.* IFSC Code*

AML GUIDELINES
I/ We hereby confirm that all premiums have been/ will be paid from bonafide sources and no premiums have been/ will be paid out of proceeds of crime related to any of the offence listed in
Prevention of Money Laundering Act 2002. I understand that the Company has the right to call for documents to establish source of funds. The insurance Company has the right to cancel the
insurance contract in case I am/ have been found guilty by any competent court of law under any statues, directly or indirectly governing the prevention of money laundering in India.
Nationality: Indian/ No- Indian
If Non-Indian, please specify Country: __________________________________________________________________
Type of Organization: Corporations/ Governments/ Non-Governmental Organizations/ Society/ Trust/ Partnership/ International Organization/ Cooperatives/ Section 25 Companies
DECLARATION
I / We hereby declare that the statements made by me / us in this Proposal Form are true to the best of my / our knowledge and belief and complete in all respects and that there is no other information which is
relevant to my application for insurance for me or the person to be insured that has not been disclosed to you. I /We and/or the person to be insured agree that this proposal and the declarations shall be the basis of
the contract between me/us and/or the person to be insured and SBI General Insurance Co Ltd and I/We and/or the person to be insured agree to accept the cover in the usual form of policy prescribed by SBI
General Insurance Co. Ltd and to pay premium.
I/We hereby extend my/our consent to the Company for sharing my/our personal data with State Bank Group entities for specific purpose of availing services offered by State Bank Group (please strike this clause
in case you do not wish to disclose the personal data).
Signature of Proposer
Date: D D M M Y Y Y Y Place:

SECTION 41 OF INSURANCE ACT, 1938

No person shall or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any
rebate of whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate except such rebate as
may be allowed in accordance with the published prospectuses or tables of the Insurer.
ANY PERSON MAKING DEFAULT IN COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE LIABLE FOR A PENALTY WHICH MAY EXTEND TO RUPEES TEN LAKHS.

DECLARATION (If signed in Vernacular language / If you have affixed thumb impression above)
Applicable where the Proposer is illiterate or is suffering from a disability due to which writing is restricted or where the Proposer has signed in vernacular language)
(Note: The below must be witnessed by someone other than the Advisor/Employee of the Company)
I/We certify that the product applied for by me/us and the contents of the Proposal Form have been clearly explained to me/us and I/we have fully understood them. I/We further certify that the replies in the
Proposal Form have been recorded as per the information provided by me/us.
I, (Full name of the witness) ____________________________________________________ (Relation with the Proposer) ________________________ adult and inhabitant of (city) ____________ and
residing at ______________________ do hereby certify that I have read out and explained the contents of the Proposal Form and all other documents incidental to availing the insurance policy from SBI General
Insurance Company Ltd., to the Proposer/Primary Insured and he/she/they have understood the same. I declare that whatever I have stated herein above is true and correct to the best of knowledge and belief.
Signature of the Witness
Date: D D M M Y Y Y Y Place: Signature/Thumb impression of the Proposer

SBI General Insurance Company Limited | IRDAI Reg. No. 144 dated 15/12/2009 | CIN: U66000MH2009PLC190546 | UIN: SBG-OT-P13-106-V01-12-13
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SBI Logo displayed belongs to State Bank of India and used by SBI General Insurance Co. Ltd. under license.
SBI General Insurance Company Limited

Cattle Insurance Policy – Veterinary Doctor Certificate Format

1. Name of the Proposer

2. Address of the Proposer

Pin Code

3. Address if animals are stabled

at other than above address

Pin Code

4. Give the following particulars in full, of each of the animals proposed for insurance (add extra sheets if required)

Type of Animal Gender Age Description of the Animal Market Value / Ear Tag No. Vaccination details

Cow, Buffalo, M/F Color Breed of animal Purpose of the Sum Insured (if any)
Stud Bull, (Indigenous/ animal
Bullock Crossbred/Exotic)

The above mentioned animal (s) was/were carefully examined by me on ____/____/____at ________ A.M./ P.M. and found to be in sound health. I certify that the animal (s) is/ are free from any pre- existing
illness, injury and are in a fit condition for Insurance. I certify that the cost of the animal (s) mentioned above is reasonably accurate.
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Signature of Veterinary Doctor Date D D M M Y Y Y Y Name

Designation Qualification Registration Number

Address

Pin Code